The dense cubicle forests of Indiana Government Center South would leave Dilbert shivering and curled in the fetal position. I really do get the heebie-jeebies every time I visit the home turf of the Family and Social Services Administration. Every door in the cleverly named South Building opens onto a ballroom filled with office dividers. Rows of tiny pods. Each one blossoms with a single bureaucrat. The important people get one of the offices that rim the outer walls like circling wagons. That's where you'll find Melanie M. Bella: superwonk.
Bella took over the Office of Medicaid Policy and Planning in October 2001 and she is fast earning the title of best bureaucrat by lawmakers inside the Statehouse. Her job is to curb rising healthcare costs for the 750,000 people on Medicaid in Indiana. It's an impossible task, made more difficult by a declining economy and rising budget deficit. Want proof? Check the premium on your own health insurance, if you're lucky enough to have health insurance.
Despite her role as cost cutter for Medicaid, she's earned high praise from lawmakers. House Ways and Means Chairman Bill Crawford (D-Indianapolis) called her a "bureaucrat with a heart" at a recent hearing. Rep. Jeff Espich, the ranking Republican on House Ways and Means, said similarly nice things, observing that she came in with fresh ideas and was willing to work with people in both parties.
She has a lot of explaining ahead of her. Though other states are forecasting double-digit increases in Medicaid, Bella is still asking for a 6.5 percent increase in 2004 and an 8.5 percent increase in the second year of the coming budget. A tough sell when the state is already forecasting an $850 million deficit.
Instead, the House passed a budget without any increase, while finding money for a modest increase in public education. Bella, a member of Frank O'Bannon's Democratic Administration, will now have to convince the Republican-controlled Senate to restore at least some of that money. If not, Bella said, the program faces Draconian cuts over the next two years.
"What people need to understand is cuts can affect other areas of the program. Sure, we can cut outpatient mental health or at-home care but we will probably end up with more people in the hospital, which will cost us more money."
Most of Medicaid is mandated by the federal government, but Indiana does provide a range of optional programs, like mental health and the much maligned chiropractic care. Trimming optional services won't make much of a dent in the $350 million cut demanded by the House. Lawmakers would have to step up to the plate and end many services if they really want to save hundreds of millions of dollars, Bella said.
Medicaid is the state/federal insurance for poor women with children, the elderly and the disabled. The largest group of optional clients in the program are children, most of whom are covered by the Children's Health Insurance Program, paid for with money from the tobacco settlement. Bella is predicting a 10 percent across the board cut for providers. Doctors haven't had their fees raised since the early 1990s. Bella expects that cutting them now will mean the state will eventually have to raise them higher than they are now to lure doctors back into the program. That's what happened when the state cut the rate for dentists in the mid 1990s.
The increases Bella is asking for in the state budget come after she cut $250 million from the Medicaid budget before submitting it to lawmakers. "It slaps you in the face that you can cut from the base but if you don't control the rate of growth, it doesn't make a difference," she said. She is trying to sell lawmakers on a slightly longer term approach, to change the way they look at the budget.
The General Assembly is not a great policy-making body. Their principal duty is to pass a two-year budget. Bella is trying to sell them on chronic disease management for Medicaid patients. About 80,000 people with long-term, chronic disorders spend $900 million of Medicaid's $1.2 billion budget. People with diabetes, heart conditions, things like that. They are often treated by several different doctors and clinics for multiple ailments. Pooling their treatment is expected to save money. The pay-off will trickle in over the next few years, as the programs come online and the cost per patient begins to drop, Bella said.
"It's very hard to convince lawmakers to think in those terms. When I say there is a pay-off but it will take a while, they say how long - three months, six months? We are starting with diabetics and I hope to see a savings in 18 months," she said.
These are the kind of jobs that age a person. It's why Family and Social Services Administration officials tend to drift through the building like dandelion seeds, staying a year or less before alighting on the breeze. Bella insists this is her dream job. Unless she is actually 17 years old, the elfish Bella seems to actually look younger as the noose tightens around her office. A lot of lawmakers are hoping she can buck the trend and at least stay long enough to see her work pay off.